Dr Jack Newman wisdom:
The post below is long, but I hope you will read it.
Breastfeeding and Medical Doctors
I will start off with a blunt, provocative statement: Most medical doctors do not know the first thing about breastfeeding. This can be extended to most health professionals as well. In addition, too many can be described fairly as anti-breastfeeding.
Despite policy statements published by pediatric societies around the world in accordance with the recommendation of the World Health Organization – exclusive breastfeeding to 6 months with continued breastfeeding to two years and beyond, many physicians interfere by telling mothers who wish to continue breastfeeding that they must stop, at 6 months or 1 year or 2 years because there is “nothing in breastmilk after 6 months or a year”. I have an idea of how this came about and will return to this later.
How is it that physicians know so little about breastfeeding? Well, to begin with, breastfeeding is a very personal issue, in the way that treating pneumonia, for example, is not. Whether physicians support breastfeeding often depends on his or her own experience with breastfeeding. If the physician’s child was not breastfed, then the physician may not be very supportive. And why do some mothers not breastfeed? Well, in Western society some mothers find the idea of breastfeeding disgusting, or inconvenient in the sense that it doesn’t fit with their “life-style”, or that breastfeeding is unnecessary. But most mothers do want to breastfeeding but quit because they find breastfeeding difficult or painful or both.
And why do mothers find breastfeeding difficult or painful or both? It starts in our society which sees bottle feeding as normal and breastfeeding as a passing fad of latte-drinking, overeducated, overpaid left-leaning people who eventually will tire of the whole thing and see the light. It starts in childhood when children do not see much breastfeeding unless of a younger sibling breastfeeding. Have a look at children’s books. If babies are shown, most likely they are shown bottle feeding. Absurdly, even animals in children’s books are bottle fed. Aquarium signs of whales show the whale bottle feeding, a neat trick if the whale could manage it. And it goes on. Sex education classes in schools usually do not even mention breastfeeding. The idea of giving a doll that cries to high school girls so that they need to soothe the doll or give the baby a bottle and take care of the doll emphasizes that feeding a baby with a bottle is the way to feed a baby.
So children who eventually will be medical doctors grow up in this society and then they become medical students, who learn nothing at all about breastfeeding in their training. Even pediatric and obstetric residents learn nothing at all about breastfeeding. Okay, they may get some theoretical information, most of which is completely irrelevant when a new mother with sore nipples arrives to their office, or when the baby is crying all the time, or if the baby is actually refusing to latch on to the breast. Their answer, almost every one of them, will be “just give the baby formula”. Even if they are supportive of breastfeeding in theory, only very few know what to do in practice.
Wait a minute, why all these problems?
Most mothers in affluent societies give birth in hospital. Many will go into hospital thinking that breastfeeding basically amounts to applying part A to part B, IKEA style, and that’s all there is to it. And for many mothers that is all there is to it. Indeed, very few mothers would have problems with breastfeeding if they had an undisturbed birth and a good start with breastfeeding.
However, mothers to be are usually told that an epidural or spinal anaesthetic will have no effect on the baby or on breastfeeding. This is either an unabashed lie or the person saying it has not read the literature. There is plenty of evidence that the drugs used in epidurals/spinals will enter the mother’s blood stream and affect the baby’s alertness and ability to suckle well. Too many hospitals have too many rules, such as a baby must breastfeed every 3 hours. But the sleepy drug-affected baby may not want to feed. So the baby is often given formula, usually by bottle, which is step one in undermining of breastfeeding. Where did this “rule” come from anyway? Nowhere, it was made up.
Another made up rule? That the baby cannot lose more than 10% of his birth weight. The vast majority of women in labour, during birth and even after the baby is born receive large amounts of intravenous fluids. Some of these fluids are transferred over to the baby so that the baby is born “overhydrated” or “extra heavy”. At birth, the baby starts urinating these fluids out and returns to “normal” hydration. So the baby does not lose “real weight” and it is inappropriate to look simply at the baby’s weight to determine if the baby is breastfeeding well or if the baby requires supplementation.
Different scales weigh differently. We have seen two scales weigh 400 grams (14 ounces) different for the same baby weighed minutes apart. Most scales are not that far off, but we have seen two scales of the exact same make by the same manufacturer weigh the same baby 85 grams (3 ounces) different and this is probably not unusual. 85 grams for a 3 kg (6lb 10oz) baby is almost 3% so that a baby may lose 3% of his birthweight depending on which scale he was weighed on. Note that most babies are weighed first in delivery and then, on another scale in postpartum.
Error in reading the scale or writing down the weight are made frequently. We have documented one baby who was weighed at birth at 2.58 kg (5lb 11oz) and 5 hours later weighed 3.1 kg (6lb 13oz). Normally, babies are not weighed every 5 hours, but undoubtedly what happened was that someone looked at the baby at 5 hours of life and thought “This baby couldn’t possibly weigh only 2.58 kg”. But what if the weighs were taken the other way around? Going from 3.1 kg at birth to 2.58 kg the next day is a loss of 17%.
There is a possibility, though, that the baby indeed is not getting much milk from the breast. When mothers get lots of fluids during the labour and birth and after, they often retain large amounts of fluid and their bodies are swollen, not only are their legs and fingers but so are their nipples and areolas as well. As a result, the baby has difficulty latching on and may not get the colostrum that is available to him.
Yet, the rule seems hard and fast in most hospitals. 10% weight loss means formula supplementation. And helping mothers breastfeed successfully? Too often not even considered.
These are just two of multiple silly and unsubstantiated “rules” that interfere with mothers starting off breastfeeding with everything on their and their baby’s side. And where do these rules come from? From pediatricians and neonatologists who don’t know even the basics of how breastfeeding works and are taken up by nurses and even lactation consultants.
But many mothers and babies manage in spite of a poor start
Yes, they do. One can even admit that what is so surprising about breastfeeding is not how many mothers have difficulty, but rather how many mothers actually manage in spite of the poor start most mothers get in hospital.
But the mothers and babies are not out of the woods yet. As more and more mothers breastfeed, more are put on medications for many reasons, such as high blood pressure, an infection of a caesarean section incision, or for other infections.
Here is the secret. It must be a secret since so many physicians, especially pediatricians don’t seem to know It. And the secret is that almost no drug requires a mother to interrupt breastfeeding. I won’t go into the other secret, that far too often the medications are not necessary. But assuming the drug has been prescribed, most mothers will be told they have to interrupt breastfeeding while they are on the drug.
This is almost never true. The amount of any drug that gets into the milk is tiny, in many cases zero, yet mothers are told they must interrupt breastfeeding. The a fairly common example is a group of drugs called monoclonal antibodies that have trade names such as Enbrel, Remicade, and there are more on the market every day it seems. These drugs are used to treat inflammatory illnesses such as rheumatoid arthritis, ulcerative colitis, psoriasis, immune diseases such as multiple sclerosis and many other illnesses. Some versions are now being used to treat some cancers. And they are being used more and more. Yet these drugs do not enter into the milk because they are very large molecules and cannot enter the milk. In fact, even if they managed, somehow, to get into the milk (extremely unlikely, vanishingly small likelihood), they would be digested in the baby’s stomach and gut, just as all proteins are digested and monoclonal antibodies are proteins. And if, somehow they managed to get past the stomach acid and pancreatic juices (extremely unlikely, vanishingly small likelihood), they would not be absorbed into the baby’s blood. They would end up in the baby’s diaper.
And yet, mothers are being told they must stop breastfeeding if they take these medications.
Mothers are still being told that they must stop breastfeeding for up to 72 hours after investigations such as magnetic resonance imaging (MRI) and Computerized Tomography (CT scan) even though the American College of Radiologists published a bulletin in 2001 that it was not necessary to interrupt breastfeeding at all after these tests.
Mothers are constantly being told they need to stop breastfeeding when taking antibiotics, though I cannot imagine why. Often the doctor will prescribe the same antibiotic for the baby on another occasion.
If the mother is not told to stop breastfeeding because of the medication she is on, she is told to stop breastfeeding if she has an illness, particularly an infectious disease such as influenza or pneumonia or a breast infection or strep throat or shingles. And yet doctors know that most infectious diseases have an incubation period and it is usually during the incubation period when the mother doesn’t even know she’s sick that she is likely to pass the virus over to the baby. Mothers and babies share all their germs. By the time the mother knows she’s sick, she has already passed the virus or bacterium over to the baby and the baby’s best protection against getting sick is not to stop breastfeeding but to continue breastfeeding. Breastmilk is chock full of immune factors, not just antibodies. So why are mothers being told to stop breastfeeding? Because too many doctors don’t think, they automatically tell mothers to stop breastfeeding.
Stop breastfeeding because there is nothing in breastmilk after 6 months or a year
It is believed by many health professionals that there is no “nutrition” in breastmilk after 6 months or a year of breastfeeding, that by this time, breastmilk is essentially white water. This is complete rubbish, but I believe it comes from the observation that many older babies are on the breast for long periods of time and yet do not gain weight adequately. We see many mothers who have what I call “late onset decreased milk supply” due to a variety of causes. Breastmilk still has lots of calories, protein, carbohydrate and fat indefinitely after the birth of the baby. But thinking “bottle feeding”, the physician sees the baby sucking at the breast and concludes the baby must be getting milk. But a baby is not getting milk just because he is latched on and sucking. Doctors have not learned how to know a baby is actually getting milk from the breast. It’s so simple, but in order to know if the baby is getting milk the health provider needs watch the baby at the breast. See really good drinking http://goo.gl/xowpj6 and nibbling http://goo.gl/b8OUVW As a result of this belief, mothers are often told to stop breastfeeding their 6 month old or 12 months old even if breastfeeding is still going well.
Can breastfeeding problems be treated?
They can be prevented if mothers are given help immediately after birth, being shown how to latch a baby on, how to know a baby is getting milk, how to help the baby get more milk using a technique called breast compression (see Breast compressions work https://goo.gl/H1T1ws, Breast compressions 2 day old https://goo.gl/dy3m0c and Four day old, breast compressions work http://goo.gl/2eIjlq
In our breastfeeding clinic, we treat mothers for sore nipples, the baby not getting enough from the breast, the baby refusing the breast and we often can manage to help the mother even though we see too many mothers and their babies much too late, often 6 weeks to 4 months after the baby’s birth. Yet most doctors have only one answer to all these problems. And that is “Stop breastfeeding” or “Just give the baby the bottle”.
Because so many mothers are undermined in their desire to breastfeed, breastfeeding now has a bad rep: “Breastfeeding is painful, breastfeeding is difficult, breastfed babies are not happy babies, breastfeeding is a risky business as babies can starve”.
What do the majority of doctors know about breastfeeding? A blank page would tell the story.
What do the majority of doctors not know about breastfeeding? This article is a mere summary.
“But Mikael Knip, a professor of pediatrics at the University of Helsinki and a senior author on the study, describes Russian Karelia as resembling Finland before World War II. It’s relatively poor. Many families in the study drink untreated well water. Russian kids have more fecal oral infections, such as hepatitis A, suggesting more sharing not only of pathogens, but of microbes that may benefit health. And previous studies have found that Russian homes harbor a richer and more diverse community of microbes than Finnish ones.”
i really hate it when i hear moms say that they can’t eat this that and the other because it upsets the baby.. this may be the case in very rare cases but i think that often it is the product of mom-shaming by doctors who seek to use breastfeeding as a scapegoat and recommend severe restrictions to the mom or formula and an ‘easy’ solution.
Last week I was at a big family dinner and my sister in law’s cousin was there with her 10 day old baby girl. From the first few minutes after she walked in I was already judging her as all parents do of each other’s children and baby raising practices. I was judging her because she was feeding her baby from a bottle. Such a little baby drinking from a bottle always confuses me and saddens me because I know that in most likely cases whatever issue has led to formula-feeding probably could have been and definitely should have been resolved. But as I watched her feed this little baby from the bottle and saw the baby guzzling down this milk, I looked more closely and I had this feeling it was breastmilk, since I know how that looks compared to formula. I didn’t approach her at first, I figured she didn’t want that. But then later my mother suggested to her that she should speak to me because clearly she was upset about what was going on with breastfeeding her baby. What I learned was ridiculous. For no apparent reason her pediatrician had told her when the baby was three or four days old and had lost the expected 10% of her birth weight, just barely, that he was concerned about her weight and that she should be supplementing with formula and if she really wanted to continue breastfeeding she should be pumping after a feed and then feeding the baby with additional breastmilk from a bottle at any and every opportunity. I was floored. There were no complaints with this baby. She was born at 9 and a half pounds, and the mom had had a C-section and an IV so clearly there would have been more fluid in this baby to lose in the first place. She was making wet and dirty diapers normally. She was relatively content. But for some crazy reason, which is the case with so many pediatricians that parents trust wholeheartedly, this mother was made to feel as though she was doing something wrong by trusting her body to feed this baby. She knew it sounded crazy and she really wanted to make breastfeeding work. But without a science or medical background herself who was she to argue with this professional? So after that appointment she had started pumping all the time, stressing herself out, and this led to bringing the bottle of breastmilk to this family gathering. Sure, she was inhibited about nursing in public because she was new at it and that is understandable. But the last thing she needed was to feel like she had to juggle the bottle and the breast because of something a supposed professional had told her. As we were speaking, she was trying to BF, and it was really OK! There was nothing obvious wrong with baby’s latch or feeding. EVERYTHING WAS FINE. Until this mama was nearly sabotaged. Things I told her:
– stop pumping until you really have to (baby will be 4 months when she goes back to school)
– yes Daddy being about to feed baby is cute but there are other ways to bond that don’t disrupt establishing solid BF skills and supply
– find another doctor
– doctors don’t know $hit about breastfeeding
– she’s doing a great job
– her body has evolved to do this
– every time baby cries, shove a boob in there
As to the latter point, this worked 90% of the time with Q and maybe 40% of the time with K. But the important thing for this new breastfeeding mom to recognize is that there’s nothing wrong with using the boob as her front line of defense against a crying baby. Mamas have been doing that since boobs have existed. Having the bottle of milk there just totally confused everything.
I told her to find her mama tribe – aka some good Facebook groups and her local lactation support group.
This sort of thing happens every day. And most of the time, there’s no lactating superhero to swoop in and set things right.